173008755-7-14-2022-01-CC-SPHG-CGBN7F-20220714101240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 173008755
Report Date: 07/14/2022
Date Signed: 07/14/2022 10:12:52 AM

Document Has Been Signed on 07/14/2022 10:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BLOCKER, SHERRI FCCH		FACILITY NUMBER:	173008755
ADMINISTRATOR:	BLOCKER, SHERRI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(707) 298-4474
CITY:	LAKEPORT	STATE: CA	ZIP CODE:	95453
CAPACITY:	14	CENSUS: 0	DATE:	07/14/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Sherri Blocker		TIME COMPLETED:	10:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sebastian Phouthavong arrived for a scheduled visit for the purpose of inspecting the facility prior to the licensee going to active status. Annual licensing fees are current. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently three adults living in the home. During today’s visit the home and grounds were toured and the facility sketch verified. Operating hours will be 7:30AM to 5:30PM, M–F. The living room, playroom, little room, kitchen, one bedroom, and the bathroom are on-limits. The off-limits areas are the master bed/bath and two bedrooms. The home appeared clean and orderly. There was a working telephone in the home. Items which could pose a danger to children (detergents, cleaning compounds, sharps objects, and medications) were stored out of the reach of children. The licensee reported that there were no poisons at the home, and none were observed during the visit. There is a working smoke detector, carbon monoxide detector, and fire extinguisher rated at least 2A:10B:C in the home. Licensee stated that there are no firearms on the premise, and none were observed. The children use backyard as the outdoor play areas, and they are completely fenced. The licensee's pediatric CPR and First Aid certification expires 7/2024. Mandated Reporter Training was last completed on 7/2022. A sample of children's records were not reviewed as no children are currently enrolled, children's record forms were reviewed with Licensee. The licensee is not currently providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian Phouthavong	TELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BLOCKER, SHERRI FCCH	FACILITY NUMBER: 173008755
	VISIT DATE: 07/14/2022

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The following information regarding ADA was provided: US Department of Justice toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Exit interview conducted and report was reviewed with the licensee, Sherri Blocker

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's visit.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian Phouthavong	TELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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